On alternative medicine

The most “open-minded” thing I’ve done this year is to try this so-called natural medicine thing from a consumer point of view. Whenever I tell this story people almost gasp in disbelief: Yes, me, an Australian-trained doctor trying this thing we have been taught since medical school is mostly witchcraft. And yes, I admit, that is (or at least was) my own view on this. The common medical literature tells us “natural medicine” is not scientifically-evaluated, poorly understood because for the most part it’s not in line with the common biopsychosocial model of medicine, and that it’s potentially very dangerous.

Sometimes patients ask me what my views on natural medicine are, and essentially they mean to ask my medical opinion on whether certain natural medicine treatments will help their condition or not. My response is almost always the same: “If you believe it’ll work, it probably will. If you don’t, it won’t”. I don’t know if that’s true, but I’m pretty close to certain that it is true when we are talking about homeopathy. My response is also an acknowledgement to the God-blessed and irrefutable placebo effect. And that is about the extent of my knowledge on non-Western (or alternative) Medicine.

My experience with alternative medicine until a few weeks ago did not leave me with the best of impressions, and they were mostly experiences I had had through my patients. However, before starting to share some of these experiences, I would like to say that I don’t intend to vilify or defame something which I have just admitted to understanding so little, in telling these few stories.

The most recent gimmick I fear for my patients sake are the “full-body scans” that promote themselves as being ‘scientifically-proven’ for the diagnosis of a multitude of vague complaints. They spit out beautiful 3D images and buzz words like “inflammation” or “congestion” and the name of a body organ. Patients pay hundreds of their dollars for the beautiful colour printout they get after having their temperature, blood pressure, pulse, and maybe even respiratory rate measured. But the point is they get what they want because some manufacturer has figured out how to give the patient what he wants (to be taken seriously, to feel cared for, education about his condition, etc.) in exchange for what he wants (money). Oh and how it breaks my heart to have my patient come back to tell me he has stopped taking all his heart medication because the printout said nothing about anything being wrong with his heart only about his spleen being ‘congested’. Or sometimes they’ll come back with a list of obscure tests the naturopath or someone has asked he have checked though you think they are not clinically indicated. So you explain to the patient that those tests may be performed privately, with the cost to the patient, and suddenly they think you are the devil because you are the one who told them about the cost even though it’s not a price you’re setting or something you even think they need… There are many frustrating stories out there from clinicians whose patients have sought the services of an alternative medicine practitioner and some have happy endings and some drastically worse, but what I really wanted to share this week was about my personal experience.

Now, a few weeks ago I allowed my mother to talk me into trialling some “alternative medicine” through a Chinese medicine practitioner one of her friends had recommended. This is the common referral method in this field; word of mouth. So I went along to see this gentleman about a vague diagnosis of “depression” which mum had noted I had increasingly being struggling with (since a recent change in my life circumstances, so probably not even real clinical depression but a temporary low mood). But, hey, I thought I had little to lose so I went. The nice Chinese man with only basic English began by taking a routine medical history and a brief clinical examination (checking some aspect of my pulse and looking at my tongue). He asked about medication I was taking, and after looking at my tongue told me I had a problem with indigestion and ‘loose stools’. He also said I don’t like change and that is why I had “depression”, it was so easy, he said, to see that in me (I call that being human, but whatever).  And he said he could help me if I followed him. Then he took me to another room for acupuncture.

As I lay down on the bed, knowing how “well-educated” people consider me to be, I felt I truly had no idea what was going on and what was going to happen or the mechanism by which it was meant to help my very vague collection of symptoms (including the ‘loose stools’ or ‘indigestion’ which I had not noticed or even bothered me before, and the reactive low mood in response to some changes in my life). I remembered what I told my patients, and I decided to trust the guy about to stick needles in me. I wondered if he could sense my ambivalence and distrust, but truth is it doesn’t take any kind of professional to recognise that in another human being. I wondered just why I was going along with this: To “cure” myself of ailments I probably didn’t even have? To please my mother? To see what all this ”quackery” was about? I think it was a combination of all the above, but despite my reasons, I knew there was nothing imaginary about the needles about to pierce my skin.

He came back in the little cubicle with (to my relief) sterilely-packed acupuncture needles and ethanol wipes. He inserted 11 needles in me, on both sides of my body: 2 near the fibular head, one posterior to the medial malleolus, one on the palmar aspect of my wrist, one just behind each mastoid process, and a final one on the very top of my head into my scalp. What I’ve always being told about acupuncture is that they use tiny tiny needles; what I didn’t realise until the day of my first session was that these tiny needles still hurt! After I had the needles inserted, I was left in the cubicle for 30 minutes and a soft harp music was played over the speakers.

I didn’t know what I was supposed to think about for those 30 minutes, so I started thinking all sorts of things. I couldn’t move because every time I moved, sharp stabbing pains would shoot through the spots where the needles were in me. First I thought I was meant to focus on the music and just relax, however I was in the middle of an Asian-dense shopping centre and people were talking and shouting and that kept distracting me. Then I thought I might focus at the point tenderness the needles were causing me, but that got old pretty quick too. So I started to try to decipher how the whole acupuncture thing works. The guy who put the needles in me hadn’t explained it to me, but actually I remembered that one session in medical school where we briefly discussed about alternative medicine. It was something about Chi channels, which don’t correlate to lymphatic or nervous or vascular channels and have possibly no anatomically corresponding structures to account for them. Then something about the balance of the Ying and Yang, which are some metaphysical constructs related to health and life in general… Oh Gosh, I was half making it up and I was still no closer to understanding what I was at that moment meant to be going through.

Finally the 30 minutes were over and the Chinese medicine practitioner told me to get up and follow him. He asked how I felt. Um, I felt like I had just had being laying down for 30 minutes listening to relaxing music while having needles pierced in my skin. What was I meant to feel? Spiritual enlightment? Physical invigoration? Relaxed? I felt relieved, honestly, because my neck was sore and I needed to change my posture. So that’s what I felt, relief; but I didn’t think that that was what the nice Chinese man wanted to hear so I said I felt “better”. I remembered how I sometimes treat patients for things they don’t fully understand (though I try to explain) like hypertension. I tell them the medication won’t make them “feel” any different, let alone any better, it’s not meant to. They may not feel sick, but untreated high blood pressure increases you risk of things no-one wants to have like heart attacks and strokes. So they take the medicines I give them though they don’t notice any change, except maybe some side-effects, and they trust the 2 minute explanation I have given them as to why it’s good for them. I felt a bit like that with my Chinese medicine practitioner, though he asks me how I feel. I like this guy, he’s a nice man, he is trying to achieve something with me here, so though I don’t know what the right answer is, I don’t want to call either him or myself a failure... Better, I must feel better.

He charges me more than I would charge a patient for a consultation of equal duration and he picks out some pill boxes from his shop, all in Asian writing I can’t understand. He says take 40 of these tablets twice a day. What?! No, no, it’s fine, he says. He tells me he can “guarantee” they aren’t going to cause any side-effects; that they are free of these evil “chemicals” the medicines I prescribe have. Of course, they are “all-natural”. I ask what they are. They are “natural remedies” with “natural” ingredients to treat my loose stools and indigestion. Oh yeah, those things that weren’t even causing me any discomfort. He books me in for a further 4 acupuncture sessions which will make me feel even “better”. My heart sinks because my mother has heard this whole exchange and she’s ecstatic!

I went along to the other 4 sessions, my mother kindly driving me in and even offering to pay my fees. My mood is still a bit low and my self-esteem a bit shattered from the personal difficulties I had faced a few weeks earlier, so I don’t have the courage to say no. I even take the 80+ tablets twice a day for a few days until I get constipated… At my second acupuncture session he asks whether I have stopped taking my other “non-natural” medicines yet. I didn’t know I had to, but no, I haven’t. I understand the potential side-effects from stopping my medication abruptly. A cold chill goes through me thinking that this is exactly what my patients face, and no wonder they do stop their medications and suffer the consequences. It seems so cruel to me. He asks if I feel better. Well, time is helping heal my emotional wounds that had being inflicted some weeks ago, and I’m pretty sure that would have happened despite the “natural remedies” and acupuncture; but yes, nice man, I am better. Is the “indigestion” better? Am I free of the ‘loose stools’ yet? Yes, nice man, I am free of those things I didn’t even know were problems... Eventually, I’ve spent so much money, I have got so much “better” (judging by what I am telling the nice man), and my self-esteem and normal affect have returned that I just can’t continue this whole thing.

And am I better because of the intricate placebo I have just trialled? Or am I better because I never was ill? I don’t know, but I have at the least realised the effect of faith has on healing. When my patients seek alternative medicine methods, they are usually at their most vulnerable and desperate to be well again. I would be better to see them more frequently, to engage them, to ask (maybe demand?) improvement from them. Maybe if I keep asking them if they are better, maybe if I keep seeing them once or twice a week, maybe if I make them believe the challenge is not just his but his and mine, maybe if I keep asking him to take his medication time and time again, maybe if I pay him personal human to human attention, he will get better. And I think that is the lesson in this for me: that is the kind of practitioner we need to become a bit closer to being, rather than leaving all these tasks to the alternative medicine practitioner, who may or may not also give the best medical advice.

On money and healthcare: Rights & Priorities - Part 3/3

As a doctor you often see people in a very vulnerable state of health walk into your room. Your job is to provide some sort of health care to that person. It is a paid job just like anyone else’s job for which they trained and invested time, effort, and money. Why any of us decided to become doctors and not hairdressers, teachers, politicians, carpenters, etc., is different for everyone and that is not the point. The point is we are workers same as anyone else doing any job. You do the job for a certain amount of hours, you get paid for doing that job, and then the money is yours to do as you wish. That’s the essence of working in a capitalist, democratic country like Australia and the U.S.A. regardless of what your job actually entails, right?

The doctor is a bit like a hairdresser or an accountant or a lawyer or a politician in that he doesn’t physically sell you a product, but rather a service. A patient walks in, you carry out an assessment, work out what he needs, and advice or give that treatment required. Patients don’t leave the room with a new bag filled with products they’ve purchased, but the same thing happens once you leave your hairdresser or accountant – and yet you are aware you need to pay for the service provided to you. And yet you could say that the service provided to you is at least a little more essential than a haircut or advice about things other than your health. One of these things could potentially be the difference between life and death. I have never heard of anyone who risked death by having long or unkempt hair…

So here is the dilemma I wanted to get to: health, or the access to health care is an essential human right; it is a right every human being regardless of who they are or what they possess deserves for the simple act of having being born human. In countries where there is widespread poverty and having no money really means having no money (i.e. none to spare on food or clothing or housing, and not just meaning poor as in having no money for a tv, a car, a haircut, a holiday, or entertainment, etc.), having a right to free access to health care is one of the great achievements of humanity.

So why am I singling out ‘poor’ countries as separate to developed countries like Australia? Because in developed countries like Australia, we believe that if we can’t afford a holiday or a car or costly entertainment that we are poor. And we don’t want to miss out on these things! To a person in a wealthy country like this, we believe that these things are our rights too - and God forbid that we miss out on these things to pay for what we now consider non-essentials, such as our health care. And that is the cause of the dilemma in wealthy countries: we have for the most part changed our priorities as to what is considered essential and non-essential. Yet we all have a sense of what our human rights are. I will tell you that in Australia we see time and time again people who hesitate and complain about having to pay an out-of-pocket fee to have their health tended to, but will without hesitation hand over large amounts of money for haircuts, for manicures, for holidays, for fancy cars, for video games, movies, etc. And yet, only one of these things could potentially be the difference between life and death…

I don’t know what the right answer is. And I don’t know what the best system of health care is. Surely everyone deserves the right to access health care regardless of what they have or who they are or what they do with their lives. Yet, surely, we have also come to some concerning conclusions when tending to our health is considered less of a priority than funding our non-essential commodities. Personally, I have only ever considered the doctor’s role as equivalent to the mechanic’s, to fix the machine so the machine can go where it chooses and do what it chooses. Doing our job doesn’t make us special people, we just do a special task. But it is a job same as being a mechanic is a job - and in this society, a job implies compensation. Doctors eat too and pharmaceutical companies are not charities, so the reality of it is that health care has become a business. It’s not ideal, but it is the reality.

On money and healthcare: Work & Subsidies - Part 2/3

In Australia, up to 80% of general practitioners accept the rebate provided by Medicare as the total cost of their medical consultation service. Essentially that is to say that they provide to Australian citizens with a Medicare card a “free” consultation service with no out-of-pocket cost to the patient (excluding medications sold through a private pharmacist). That’s a great thing for patients! They can’t use the ‘I don’t have enough money to go see a doctor’ excuse too often since most GPs will see them for "free". Of course, the doctor has to get paid, too – because medicine is a job, not a charity – and Medicare will pay him for doing his job. However, remember, how Medicare is a rebate and not meant as full payment of the doctor’s service?...

There is a big group of people in non-government health care systems (e.g. private allied health professionals, private medical specialists, and around 20% of general practice doctors) who don’t accept the Medicare rebate as full payment for the service they provide. Are they the “better” health professionals, worthy of more money than Medicare provides for? Are they greedy ‘fat cats’ like some politicians will call them? No. They are the same as other health care professionals providing similar services. Often they are the same people who will see some patients at a fully-subsidised cost or charge an additional fee on top of the rebate. They’re not bad people; they are just people in paid employment. They’re people working in a private system practising within their legal right to set their own fees for their service, often actually very realistic fees to cover the true costs of doing their job. Unfortunately, because both types of practitioners operate within the same country, the one who charges what he or she has deemed his service is worth is seen as some sort of evil, money-hungry, exploitative person. Conversely, the one who provides “free” (to the patient) services is often considered less than – and this is what most general practitioners in the eyes of the public are seen as.

On money and healthcare: Rights & Systems - Part 1/3

Rights

“Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services”  (Article 25, The Universal Declaration of Human Rights). The World Health Organization defines health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity”. Of course, to the majority of the world’s population, complete attainment of our human rights and of health are only ideals and not reality. Nevertheless, they are ideals worthy of our consideration.

Ideals

In an ideal world every time someone fell into an unhealthy situation (physically, mentally, or socially), he should be able to access medical health care, mental health care, or social care and have his “health” restored. He should be able to access these things regardless of the amount of money he has, his sex or age, his political or religious affiliation, his ethnicity or language, his sexual identity or practice, his birthplace or site of residence, his employment status, etc. Basically, his right to health care is universal and his human right. That’s the ideal; reality is very different for a lot of reasons.

Reality

Every country has different health care systems, which impact on the way patients access health care. Some countries will have a health care system that is exclusively government-funded and all you may need to access it is proof of citizenship to that country. Usually that means that there is no cost to the patient for an “encounter” (i.e. every time you access health care) as funds are usually derived from a portion of pooled taxes payed by that country’s citizens. Other countries may have a system where accessing health care requires payment to a private health care facility or a private company that coordinates provision of health care (e.g. supplying and paying for the medical staff’s wages, the medical equipment, the facility fees, etc.). A lot of developed countries, Australia included, operate both of these public and private health systems concurrently where the public system is the default for all citizens unable to afford private health care. The private system exists and thrives because it promises certain perks and advantages like your choice of health care provider, faster access to elective surgery, more ready access to specialist medical reviews and allied health services, and often newer premises, medical equipment, and technologies. And yet other countries have a third system, like a lot in South and Central America, a “worker’s” health care system that provides health care services exclusively to that country’s citizens whose employers pay for access to this service. The worker’s health system is closer (or equivalent) to the private health care system than to the public system. I don’t intend to argue which system is better or which worse or which country does it best, but it’s interesting to consider what’s out there.

Australia

Australia has a dual system of public and private healthcare, the public system funded from federal money and managed (for the most part) at a state level. Medicare can be considered a pool of federal monies reserved for funding certain medical services (including surgical fees and the payment for medical staff), medicines, medical aids, etc. All citizens have access to those Medicare funds provided certain criteria are met, but generally it is a default system for everyone.

An often misunderstood peculiarity of the Australian government’s Medicare system has to do with the way a doctor bills his or her patients. The Australian government decides which medical services are worthy of a Medicare rebate, the amount of money allocated to it, and the conditions under which a service qualifies for a rebate. For example, anybody may approach a general practitioner for medical care and Medicare will provide a certain benefit to the patient to pay for that consultation. The patient may also approach a specialist doctor and pay for the full cost of seeing him in his private clinic; or he may present to his GP first and obtain a written referral to the same specialist and then become eligible for a rebate from Medicare to help pay for his medical specialist appointment. (A patient not wishing to access the private medical system at all for any reason may also be referred to a specialist in one of the state’s hospitals where it is available and obtain medical specialist review free of charge.) Importantly, the Australian government decides which medical services qualify for a Medicare rebate and how much money it allocates to each service – however, how much money Medicare allocates to a service does not always reflect how much money a service actually costs to provide. Medicare in fact operates as a rebate, a subsidy to the total cost of health care, not (at least not always) as the absolute cost to cover the service. Think of it as a discount voucher, not as a voucher for a “free” service.